Preserving the brains—and dignity—of ICU Patients: A Decade of Published Work

In 2004 the ICU Delirium and Cognitive Impairment Student Group published a paper in the Journal of the American Medical Association (JAMA) that provided the first documented cohort study to include daily measurements of delirium in the ICU. The study found the development of delirium presents the patients with a 300 percent increased likelihood of dying by six months (independent of other predictors) as compared to similar patients who didn’t develop delirium. “The dilemma in critical care is that people often develop brain dysfunction or delirium in the ICU setting which is erroneously thought to be of no real importance to survival or long-term quality of life,” Wes Ely, M.D., MPH, said at the time. “Frankly, it’s been overlooked by medical teams for years and in the past was simply called ‘ICU psychosis.’”

In 2006, Pratik Pandharipande, M.D., MSCI, professor of Anesthesiology and Critical Care, worked with Ely to publish data in the journal Anesthesiology that for the first time showed that benzodiazepine sedatives were a striking predictor of delirium in ICU patients. At that time, these sedative medications were almost universally prescribed to reduce anxiety and to keep patients sedated while on mechanical ventilation.

In 2007, Pandharipande and Ely published a study in JAMA that found that sedation with dexmedetomidine resulted in more days alive without delirium or coma and a lower prevalence of coma than sedation with lorazepam (a benzodiazepine). Taken together, these highly cited studies contributed to a large shift in thinking, spawned other studies, and have led to guideline recommendations against widespread use of benzodiazepines.

In 2012, the group received a $2.8 million grant from the National Heart, Lung, and Blood Institute (NHLBI) to compare the effects of sedation with propofol versus dexmedetomidine. This ongoing randomized, controlled trial is an example of the type of difficult-to-orchestrate multicenter trials that the ICU Delirium and Cognitive impairment Study Group undertakes via its coordinating center and team of experts. They have an even larger ongoing study that is a placebo-controlled, NIA-sponsored trial called MIND-USA, to determine the role of antipsychotics in managing delirium.

The most startling findings, however, came in 2013, when the group published a study in the New England Journal of Medicine that indicated patients treated in intensive care units often leave with deficits similar to those seen in patients with traumatic brain injury (TBI) or mild Alzheimer’s disease that persist for at least a year.